Friday, January 7, 2011
On my mind this evening is the fact that I have to go back to work tomorrow and take care of a big fat faker. a PHONY!!
He claims to have cyclic vomiting syndrome. Look it up, it involves repeated bouts of vomiting. It has a psychiatric component, but the people (and here's the rub) do actually vomit.
Reasons I had a problem admitting this patient.
1. My senior resident foisted it off on me for no other reason than the fact that he could. Bastard.
2. Reading the note, something stank. This guy was referred here to see a particular GI doctor. At 3am, he had woken up with abdominal pain, then started vomiting, yada yada. His mother (uh, yeah, he's 36 years old) brought him to the ED, where he got a $2000 workup which was totally normal, was given IV fluids, and sent to his GI appointment. According to the ED note, he never actually threw up. When he was told he wasn't going to be given the dilaudid his primary care provider did not feel comfortable writing for anymore and instead sent to his clinic appointment, he "spit up" (from the note) in the trashcan.
3. After that episode, he proceeded to put on such a show in the GI clinic that the specialist called US and said he was too sick to go home. So we had to admit him.
4. Nobody wanted to re-admit him to the ED because they had already worked him up for nothing, so I took the senior medical student down to the triage area they'd put him in, showed them into the ECG room where we could examine him in private, and told the med student: "I don't trust my filter right now, so I'm going to introduce myself, introduce you, then let you do the talking. I'll interject when I have more questions and I won't let you miss anything, but I'm going to mostly keep my mouth shut and keep us out of trouble."
5. This guy was wrapped in a blankie hunched over like a two year-old in a wheelchair (which he had very recently been peacefully napping in according to the nurses), then as soon as we got him, Mom, and sis in a room he began rocking back and forth banging his hands and making unintelligible grunts. Luckily, Sis and Mom were all over it.
"Do you need water?"
"Do you need something to throw up in?"
"TRASH CAN RIGHT NOW"
"Do you want me to rub your back?"
"Do you need a drink of water right now?"
For the love of Zofran, this was some sick s@#$ going down. I would have thought the guy was autistic or developmentally delayed, but according to Sissy and Mommy, who also provided all the history down to the fact that he'd eaten about half a meal of pasta at 8pm last night--oh, no, you had some crackers and milk at 11--he used to be an engineer, prior to this vomiting and needing to go on disability and moving into his parent's basement apartment.
All of this would be pitiable, sad, yeah, a little weird with the drama-loving duo hovering so intensely I expected them to do a poop check any minute (something parents do to babies if you're not in the know), except for the very very important number:
6. That was a fake vomit.
I know my way around a vomit people. That was a fake. A crappy, unconvincing, F-U for effort fake. He basically coughed a few times, went "HUuuuhhHH", and spit clear just-outta-the-mouth spit in a trash can. Once.
Here's the thing about vomiting-if you're really committed, you can make yourself puke. It's called bulimia if you're really good at it. If you're not even that committed , don't try to pull one over on a pregnant lady. Not only do I know every which way to vomit, the fact that you're trying to fake me out after I've been eating saltines and Sprite for 8 weeks is going to piss me off.
He wanted dilaudid, he wanted IV ativan, and he wanted attention. And the fact that he was caught by nursing doing oh just fine (I can just picture him soft shoeing while eating a pudding snack) until Mommy walked in the room (at which point, more fake vomiting), and I can't go back tomorrow and say, "You have to leave." is one of the reasons I don't belong in patient care.
Hopefully I have a medical student to keep me professional.
Thursday, November 11, 2010
I walked in to a patients room this morning with this history: 50-something male who blacked out while driving Sunday, losing control of bodily functions, crashed his car into a pole, woke up and decided to drive himself home, then spent the next few days occasionally blacking out while continuing to drive himself around town. That is, until he decided to drive himself to the emergency room.
He had a history of cancer, drinking, and has enjoyed more drugs than there are ways to "just say no".
I'm real excited to meet this dude.
I head into the room, and he looks like he's been rode hard, dragged through some cacti, and put away wet. He has multiple scratches and thick blood-crusted scabs and bruises on him. His hair is thin all over. He is painfully thin. He looks a little wild-eyed. Then there's the trach that he cleans with his hand (imagine you could reach into the back of your throat and pull out all the snot and spit with a swipe of your hand, only to wipe it on the front of your gown before offering your hand to shake with the doctor).
"How are you doing today?" I lead with. Pretty benign, usually. He grunted something and grabbed his belly just around his stomach under his ribs--you can't talk and use both hands at one time with a trach, you need one to push your speaking button.
"Does your stomach hurt?" I asked next. He responded by clutching his stomach, holding up one finger in a "just one moment please ma'am" gesture, then, jeez this deserves a new paragraph:
He then took that one finger, pushed his trach button, and without a word, turned to his left, and projectile vomited coffee ground looking emesis, managing to arc it from his bed into a trash can.
This was not that man's first time around a vomit.
I am positive my head left a dent in the wall behind me because my first and only instinct was to back up so fast I flattened myself against the first surface I hit. Seriously, I moved so fast my arms flew up; it's probably more like a snow angel impressioned in the paint.
The guy had just had coffee, otherwise as you know if you're in the medical field seeing actual coffee colored emesis means the dude is BLEEDING in his throat or stomach, both of which could happen in a man with his history.
When he was done, he turned back to me, pushed the speak button in his trach and said, "SORRY. BEING AROUND PEOPLE MAKES ME NERVOUS."
"That's ok. I might throw up myself," I said.
Probably not the most doctorly thing to say, but come on, I'd just about given myself a concussion and two weeks ago I wouldn't have even been able to get words out before I yakked on his hospital bed. But it actually worked out; this guy started to laugh, and I could tell he was visibly more comfortable with me after.
The title of the blog comes from other events in this guy's day. A few conversations passed to me:
Neurology: "How much do you drink?"
Mr Bad Decisions: "I don't drink."
Nurse: "Your blood alcohol is still 0.05%"
MBD: "I only drink to take the pain away."
My attending: "So, you're having a hard time without alcohol? (the patient is in florid withdrawal by this point).
MBD: "Doc, I'm not gonna lie to you. I ran out of my Vicodin two days ago and I hit the vodka instead. It's the only thing that works for the pain. So I been drinking a lot."
Ladies and gentlemen, my favorite patient of the day.
Wednesday, November 10, 2010
I worked 91 hours last week. It is getting old. Some days I look at radiology attending positions just to remind myself that it won't be like this forever.
A patient I got really close to is probably going to die tonight. I've gotten in the habit of checking on her several times and day and again one more time before i go home. It's especially hard to leave oncology patients for some reason. I guess because most of them were going about their business when they got a crappy cancer diagnosis. It's a little different than the ones who seem to come in and out of the hospital playing the Poor Me card for painkillers or attention.
I think I actually like the Palliative Care patients the most right now. Since I'm not the final decision maker on treatment, something I can do really well is explain things to families and offer comfort.
Friday, November 5, 2010
Anyway, the point is, if you hear me use my slow, measured, somewhat quiet voice, you do not want me to have to come to the nurses station.
After being paged repeatedly and having my attending called despite asking for a few minutes to figure out what was going on with the patient, I stomped down the hall ready to rage to Death Star, a cute little nickname one particular unit in our hospital earned for having spazzy, constantly-paging nurses who somehow manage to miss things like, a blood pressure of 80/40. What do they page about? I spent two weeks and several nights on call and I still can't tell you.
"You paged me repeatedly on this issue. I have a patient with a systolic blood pressure >200, asked for five minutes to figure out what's going on, and every time you page me all patient care gets put off until I can answer the page."
I lead in with that for drama, then since I can never trust my hormones' next move, the urge to really mess with them came over me. "I have had use the bathroom for two hours but can't because I'm getting paged. I have to pee so bad my belly looks like THIS!" I then opened my white coat and gestured wildly at my newly bumped preggo belly. These nurses didn't know I'm pregnant, so the looks on their faces when they thought of how long I must have had to go before I looked like someone stretched a dress over a watermelon was PRICELESS.
"Oh my gosh I'm so sorry there's a bathroom right there I'll leave you alone!"
"Nah, I'm kidding. I'm pregnant. But seriously, I still have to go."
I am very concerned that unless I find ways to deal with the frustrations of intern life, I will have a rage baby who does nothing but cry until he learns how to yell obscenities. So I have to find ways to bring a little funny to the workday. I actually don't feel stressed the majority of the time despite working 70-80 hours a week. Of course, I say that this minute...
Wednesday, October 20, 2010
It's been difficult to write lately for various reasons:
1. I work all the freaking time
2. When I am home, I don't really want to think about the hospital. I've actually spent 4 years honing the Dr. Kelso skill of dropping my cares off when I leave the hospital. That clip is in Spanish, but it's really the faces that count.
3. Looking at a computer for a long time makes me want to vomit. Really.
4. Because I'm pregnant.
It's added an extra spice to my usual demeanor at the hospital. When I was on night float I was about 7-8 weeks along. Not eating at the normal times, sleeping about 5 hours a day and dealing with the massive stupidity that passes for RN's at night time (not all were terrible, let me clarify) meant I spent my free time eating the two things that sounded good--all fruit popsicles and English muffins, both of which I can't look at now--and popping Zofran to keep myself from throwing up too many times.
When someone woke me up for a blood pressure of 150/80, I wanted to burn the whole unit down. I am not kidding. I am seriously afraid my baby will have rage problems because of the time I spent on the night shift.
Starting Oncology has depressed me for various reasons. Like everybody is dying. And, I have to be at work at 6am 6 days a week until April. I shouldn't be awake.
Today I saw a young guy with a son who looked like he was around 5 years old. This kid was CUTE. And his dad was going home on hospice. I started to feel the crush of sadness settle over me, then I thought about the tiny baby who was at the mercy of my moods. Part of me worried about whether this would ever happen to me. Then a better part of me said, "Just flood that baby with love. That's the best thing you can do now."
I certainly wish I'd thought to do that the other day when I cried for ten minutes over an episode of Battlestar Galactica just because of a scene where a somewhat nerdy character was eating alone and looking sad and lonely. Yeah.
In the end, I really don't give a crap about this year. I am being forced to do a year of internal medicine do to an archaic system that is slow to change due to money and IM departments reluctant to give up their cheap smart labor (anyone who gets into a competetive residency that requires a prelim year is usually pretty darn competent. I don't know how I got in.) It was always going to be difficult, whether or not I was especially hormonal or occasionally throwing up. I had the thought this morning that it would be a year I'd look back on and wonder how I survived. Usually I don't realize that until after I've had the year. :-)
And now, after that round of wallowing in self-pity, you can see why I don't always blog! I'll have a funny story next.
Sunday, October 17, 2010
My elderly patients crack me up. Sometimes they are whiners, but sometimes they are the funniest things this side of an emergency room.
That title was one of my favorite quotes from one of my favorite patients. This guy got up like every other day of his life, gave his neck a pop, and broke it.
Yes. He broke his own neck.
I’ve known this could happen for years. By known, I mean the grotesque image has run through my mind whenever I see someone crack their neck, and I try to stifle my shudder and use my doctor voice to convince them of something I’m sure of, namely, that they are going to break their own necks right in front of me.
Anyway, though I believe I was proven right, I guess I should add something else to the story. He had cancer he didn’t know about, and it had grown metastases in his spine, weakening it. So he still broke his own neck, but his neck did have a few fragile spots.
Unfortunately, the cancer/contrast from the scans that found the cancer also shot his kidneys. The man has been in a halo (he has screws coming out of his skull, yes, through his skin that attach to a halo with a fabric-covered harness down over his shoulders midway to his belly button. He can’t sit up for dialysis in an outpatient clinic, so he can’t go to a nursing home. None of the Long-Term Acute Care facilities (kind hospital-lite) will take him to chemotherapy, so he can’t go to an LTACH. He’s been stuck here for over a month for no reason other than administrative policies. Plus at first they gave him a crappy renal diet, then by the time we figured out to give him whatever he wanted, the chemo had already made him lose his appetite.
You’d figure the guy has every reason to be a grump. But he’s not. He’s always upbeat. He always says, “Oh, I’m doing pretty good!” when you ask him how his day is. Every now and then he says something like, “I need you to blow me out again.” (the first time he said he was constipated, I told him I was going to “blow him out because that was one thing I know how to do well.”).
With the dialysis we realized we might have been pulling a little too much fluid off of him. My attending asked, “Do you feel like you’re thirsty?” to which he replied, “Doc, my mouth’s dryer than a popcorn fart!” I don’t even know what that means, but it was awesome to see my attending try to keep a straight face.
Thursday, September 16, 2010
One nurse called just to tell me that a patient w/ a partial small bowel obstruction (who had orders for enemas q 2 hours until she had a bowel movement, no need to call the on-call doctor), that Mrs. Pooz had a "large bowel movement that was very green. I didn't know if you wanted to look at it or do anything about it..." Wha? Yes, she really did call to see if I wanted to hike my butt up two flights of stairs and go look at poop. One of my many talents is sarcasm, which I felt I restrained by only saying, "Thank you for that very useful piece of information regarding the patient's care. Although I am very interested in bowel movements, I will not change her care plan at this time." Nurse Literal, not getting the sarcasm, responds seriously: "Oh, I can call you if she has any more like that, I think it's interesting too!" I decided to be direct. "If you call me again for a bowel movement that has anything other than frank blood, I will make you do enemas for the rest of your shift." The funny thing is, that is the comment she didn't take seriously, and then she had a great chuckle and said how funny I was and never called me again that night. And no, she wasn't mad at me, those nurses call you for blood sugars of 90 (normal) at 3 o'clock in the morning.
This morning I had a bullshit admission (Kari, I know you're an ED resident, but sometimes I could just take a hose to the place) for a lady who has been admitted once a month for CONSTIPATION, nausea, vomiting, and abdominal pain. Ladies and gentlemen, this lady is why people whine and moan about the ED being misused by people who don't pay. If this lady had any intention of paying a hospital bill, I'll tell nursing that I want to see pooh all night tonight. But she said the magic word, "chest pain" that bought her a 23 hour obs stay courtesy of Medicaid. Funny thing is, her "chest pain" resolved with an enema, leaving her only with abdominal pain. Her troponins were negative x3 (she'd been in the ED long enough to have 3 troponins, which are drawn 6 hours apart), ECG was normal, basically I was more likely to be having a heart attack at that moment. But due to attendings who were off site and an ED doc who didn't want to reverse the previous shift's decision to admit, we had to admit the lady.
Ok. You want to fix your constipation? That is something I do well.
That lady is on Miralax, Senekot, Colace, GOLYTELY, and enemas q2. She is going to be crapping food she hasn't even eaten yet. My hope is to clean her out so well no stool will stay in her body for at least another month. You're welcome.
And no, I don't want to see it.